Are any aircraft owned, leased, chartered
or furnished for regular use?

Yes
No

11

Do any drivers have mental or physical impairments?

Yes
No

12

Are any premises, vehicles, watercraft, aircraft used for business?

Yes
No

13

Are any premises, vehicles, watercraft, aircraft owned, hired,
leased or regularly used not covered by the primary policies?

Yes
No

14

Do you engage ina any type of farming operation?

Yes
No

15

Do you hold any non-remunerative positions?

Yes
No

16

Do you employ any residence employees?

Yes
No

17

Any non-owned property exceeding $1,000 in value in your care,
custody or control?

Yes
No

18

Any non-owned business or professional activities included in
the primary policies?

Yes
No

19

Does any primary policy have reduced limits of liability or eliminate
coverage for specific exposures?

Yes
No

20

Was any coverage declined, cancelled or non-renewed within the
past 5 years?

Yes
No

21

Any motorcycles, mopeds or all terrain vehicles owned?

Yes
No

22

Any other business activities conducted from your residence or
premises?

Yes
No

23

Please explain any YES answers from above

24

Are there drivers under 25 yrs of age?

25

If yes state how many:

26

What is the number of autos you own?

27

What is the number of recreational vehicles
you own?

28

What is the number of single family
dwellings you own?

29

What is the number of multi-unit buildings
you own?

30

What is the number of vacant property
(land) you own?

31

What is the number of motorcycles you
own?

32

Where there any losses or claims in
the last 5 years?

Yes
No

33

If yes, what is the date, amount paid
and description of each loss or claim?

34

What is the liability limit requested?

Social Security #:

Comments or Questions

35

36

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